Provider Demographics
NPI:1952520009
Name:HARRIS, BRENDA E (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:E
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4755
Mailing Address - Country:US
Mailing Address - Phone:336-599-9271
Mailing Address - Fax:336-599-0969
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4755
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-599-0969
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101191363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903636Medicaid
341814Medicare ID - Type Unspecified
NC5903636Medicaid